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 Pancreatic Pseudocyst
 

Pancreatic Pseudocyst

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     Pancreatic Pseudocyst Pancreatic Pseudocyst Presentation Transcript

    • Dr Batool Urooj Rajput Dr Muhammad Sameer
    • 23 year old male, with no known co-morbids admitted through OPD, with complains of:  Abdominal fullness  1 year  Nausea and vomiting  1 year
    •  Trauma followed by abdominal pain on 6/9/12.  3 mo later, abdominal pain & vomiting ass with food,  CT scan on 27/11/12  large cystic mass in upper left abdomen.  Endoscopic drainage  22/1/13
    •  Two months later , abdominal fullness & distention ass nausea & vomiting.  U/S(28/7/13)  Pseudo pancreatic cyst & Left Hydronephrosis.
    •  Not Significant Personal History  3 kg weight loss  Allergy  nil  Drug  antiemetic
    •  Father & sister  TB  Mother  HTN Socio-Economic History  N/S
    •  Young male of lean built and average height , well oriented to time , place and person.  B/P : 120/80  Pulse : 90  Temp : A/f  R/R : 18 SubVitals : A*, Cl*, J* Cy*, D*, E*, L/N*
    •  CVS: S1 + S2 + 0  CNS: Intact  Chest: NVB + clear  Abdomen: ◦ On inspection : distended, umbilicus obliterated, no scar mark , no pigmentation ◦ On palpation : Firm, nontender , large 15 * 15 cm swelling in LHC extending till epigastrium & periumbilical area, fixed with regular border & smooth surface. ◦ Rest of examination was normal.
    •  Pseudo pancreatic cyst  Acute pancreatic fluid collection  Pancreatic Abscess  Mucinous cyst adenoma
    •  CBC  UCE  LFT  PT INR  Amylase
    •  A large cyst measuring 18.8*11cm seen in the body and tail of pancreas suggestive of pseudo cyst.
    •  Pseudo pancreatic Cyst
    •  Most common cystic lesions of the pancreas, accounting for 75-80% of such masses  Location ◦ Lesser peritoneal sac in proximity to the pancreas ◦ Large pseudocysts can extend into the paracolic gutters, pelvis, mediastinum, neck or scrotum  May be loculated
    •  Thick fibrous capsule – not a true epithelial lining  Pseudo cyst fluid ◦ Similar electrolyte concentrations to plasma ◦ High concentration of amylase, lipase, and enterokinases such as trypsin
    •  Pancreatic ductal disruption 2 to 1. Acute pancreatitis – Necrosis 2. Chronic pancreatitis – Elevated pancreatic duct pressures from strictures or ductal calculi 3. Trauma 4. Ductal obstruction and pancreatic neoplasms
    •  Symptoms ◦ Abdominal pain > 3 weeks (80 – 90%) ◦ Nausea / vomiting ◦ Early satiety ◦ Bloating, indigestion  Signs ◦ Tenderness ◦ Abdominal fullness
    •  Clinically suspect a pseudo cyst ◦ Episode of pancreatitis fails to resolve ◦ Amylase levels persistently high ◦ Persistent abdominal pain ◦ Epigastric mass palpated after pancreatitis  Labs ◦ Persistently elevated serum amylase  Plain X-ray ◦ Not very useful  Ultrasound ◦ 75 -90% sensitive  CT ◦ Most accurate (sensitivity 90-100%)
    • TEST Pancreatic Fluid Collection Mucinous cyst adenoma Pancreatic Abscess Pseudo cyst CEA Low High Low Low Amylase High Low High High Mucin Stain Negative Positive Negative Negative
    •  ~50% resolve spontaneously  Size ◦ Nearly all <4cm resolve spontaneously ◦ >6cm 60-80% persist, necessitate intervention  Cause ◦ Traumatic, chronic pancreatitis <10% resolve  Multiple cysts – few spontaneously resolve  Duration - Less likely to resolve if persist > 6-8 weeks
    •  Infection ◦ S/S – Fever, worsening abd. pain, systemic signs of sepsis ◦ CT – Thickening of fibrous wall or air within the cavity  GI obstruction  Perforation  Hemorrhage  Thrombosis – SV (most common)  Pseudo aneurysm formation – Splenic artery (most common), GastroDuodenalArtery, Post. Descending Artery
    •  Regardless of size, an asymptomatic pseudo cyst does not require treatment.  Abdominal ultrasonography every 3 to 6 months.  ERCP is usually done before attempting drainage
    •  ◦ Presence of symptoms (> 6 wks) ◦ Enlargement of pseudo cyst ( > 6 cm) ◦ Complications (infected cyst, progressive cyst, multiple cysts, cyst due to trauma and communicating cyst) ◦ Suspicion of malignancy
    • ◦ Percutaneous drainage ◦ Endoscopic drainage ◦ Surgical drainage
    •  Continuous drainage until output < 50 ml/day + amylase activity ↓  Failure rate 16%  Recurrence rates 7%  Complications  Conversion into an infected pseudo cyst (10%)  Catheter-site cellulitis  Damage to adjacent organs  Pancreatico-cutaneous fistula  GI hemorrhage
    •  Indications ◦ Mature cyst wall < 1 cm thick ◦ Adherent to the duodenum or posterior gastric wall ◦ Previous abd surgery or significant co morbidities  Contraindications ◦ Bleeding dyscrasias ◦ Gastric varices ◦ Acute inflammatory changes that may prevent cyst from adhering to the enteric wall ◦ CT findings  Thick debris  Multiloculated pseudocysts
    •  Excision ◦ Tail of gland & along with proximal strictures – distal pancreatectomy & splenectomy ◦ Head of gland with strictures of pancreatic or bile ducts – pancreaticoduodenectomy  External drainage  Internal drainage ◦ Cystogastrostomy ◦ Cystojejunostomy  Permanent resolution confirmed in b/w 91%–97% of patients* ◦ Cystoduodenostomy  Can be complicated by duodenal fistula and bleeding at anastomotic site
    •  The interface b/w the cyst and the enteric lumen must be ≥ 5 cm for adequate drainage  Approaches ◦ Pancreatitis 2 to biliary etiology extra luminal approach with concurrent laparoscopic cholecystectomy ◦ Non-biliary origin intraluminal (combined laparoscopic/endoscopic) approach.
    •  Surgical drainage is the traditional approach – gold standard.  Percutaneous catheter drainage – high chance of persistent pancreatic fistula.  Endoscopic drainage - less invasive, becoming more popular, technically demanding  .Surgery necessary in complicated pseudocyts, failed nonsurgical, and multiple pseudocysts.
    •  Procedure Performed : Cystogastrosotmy  Operative Finding : Large cyst arising from pancreas displacing and compressing the stomach inferiorly.  Recovery : Smooth